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. 2019 Oct 24;28(1):12–18. doi: 10.1177/2292550319880910

Avoiding Breach of Patient Confidentiality: Trial of a Smartphone Application That Enables Secure Clinical Photography and Communication

Éviter de briser la confidentialité du patient : essai d’une application pour téléphone intelligent afin de sécuriser les photographies et les communications cliniques

Danielle O Dumestre 1,✉, Frankie Fraulin 1
PMCID: PMC7016392  PMID: 32110641

Abstract

Background:

To evaluate a smartphone application for clinical photography that prioritizes and facilitates patient security.

Methods:

Ethics was obtained to trial the application Sharesmart. Calgary plastic surgeons/residents used the application for clinical photography and communication. Surveys gauging the application usability, incorporated consent process, and photograph storage/sharing were then sent to surgeons and patients.

Results:

Over a 1-year trial period, 16 Calgary plastic surgeons and 24 residents used the application to photograph 84 patients. Half (56%) of the patients completed the survey. The majority of patients found the applications consent process acceptable (89%) and felt their photograph was secure (89%). Half (51%) of the surgeons/residents completed the survey and would use the application as is (67%) or with modifications (33%). The consent process was felt to be superior (73%) or equivalent (23%) to participant’s prior methods and was felt to resolve issues present with current photography practices of secure transmission and storage of photographs by 100% and 95% of respondents, respectively. Perceived limitations of the application included difficulties in use with poor cellphone service or Internet, decreased speed compared to current practices, the lack of a desktop platform, video capability, and ability to transmit the photograph directly to the patient’s medical record.

Conclusions:

A smartphone clinical photography application addresses the risks of patient confidentiality breach present with current photography methods; broad implementation should be considered.

Keywords: cellphone, communication, confidentiality, outpatient care, photography, smartphone, telemedicine

Introduction

Clinical photography is an important tool for both physicians and patients, providing an added dimension to patient care.1,2 Surveys assessing current habits of clinical photography among physicians demonstrate widespread use of the smartphone camera, text messaging for photograph transmission and clinical communication, and inadequate consent and photograph storage.3-7 The recommendation of using a medical photographer is difficult in the current technological climate, with demands for clinical photography increasing.4,8,9 Despite confidentiality concerns, smartphones are widely used, as they permit accessible and timely clinical photography and communication.1,2,10-12 Examples of uses for smartphone clinical photography include facilitating acute decision-making regarding burn patient’s transfer to tertiary-care sites,13-15 telemedicine among health-care providers,16-19 facilitating patient autonomy via skin and wound assessments,2,20,21 and post-operative outpatient care,22,23 with many other uses described.24-27 Despite the advantages smartphone clinical photography offers, their current method of use poses significant risks to patient confidentiality which are prohibitive to their continued use without modification.7,25,27-32

To address these concerns, we conducted a trial of a smartphone application, PicSafe Medi, in 2015.10 This application permitted secure on-application clinical photography, an incorporated consent process, and secure photograph transmission. We found that overall patient acceptance of a secure smartphone application for clinical photography and communication was high; however, application limitations such as photograph distortion, technical issues, and lack of a secure messaging component yielded poor surgeon acceptance, with only 23% who would use the application unchanged. We were encouraged by an additional 63% who would have been interested in a similar application if the limitations were overcome.

Recently, Canadian national clinical photography guidelines were developed33 and included in the Canadian Medical Association policy base.34 These guidelines address consent, photograph transmission, storage, audit/retention, and breach, specifically in the context of smart-device clinical photography. The purpose of this study was to find and trial a smartphone application for clinical photography and communication that fulfills the current policies and guidelines regarding clinical photography while being effective and efficient for surgeon use and providing high patient satisfaction.

Methods

A search of the literature and Google was conducted to identify new available clinical photography applications. PicSafe (Slay Pty Ltd, Victoria, Australia; 2018), RxPhoto (AppwoRx, LTC, Ave Boston, MA; 2012), Epitomyze Capture (Epitomyze Inc, Fairfield Connecticut; 2018), and ShareSmart (Think Tank Innovations Ltd, Calgary, AB; 2016) were found and explored. The application ShareSmart was selected for trial, as it incorporated consent for clinical photography (Figure 1), secure photograph storage separate from the phone’s intrinsic storage system (Figure 2), organized health-care professional contact lists (Figure 3), and secure photograph transmission as well as messaging among health-care providers (Figure 4). Additionally, when used in Canada, ShareSmart stores all of its data on a Canadian cloud and SOCII-certified server.

Figure 1.

Figure 1.

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Photograph consent.

Figure 2.

Figure 2.

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Secure photograph storage.

Figure 3.

Figure 3.

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Organized health-care provider contact list.

Figure 4.

Figure 4.

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Photograph and clinical messaging platform.

Ethics was obtained via the Conjoint Health Research Ethics Board (CHREB) to conduct a 1-year trial of the application Sharesmart. This article does not contain any studies with humans or animal participants. Informed consent was obtained from all individual participants included in the study. Calgary plastic surgeons and residents were recruited through presentations at teaching rounds and resident research day for voluntary participation in the study. Those interested were consented to download and use the application for clinical photography and communication as needed for daily clinical activities (patients were not photographed solely for the study’s purpose), to recruit the patients photographed to participate in the study, and to complete a survey at the study’s completion. The 22-question survey queried the surgeon’s methods of clinical photography prior to using the application (device used and consent, photograph storage, and transmission process), gauged the application’s usability, incorporated consent process, and photograph storage/sharing, and compared the application to the user’s prior method of clinical photography. Of those who opted not to participate in the trial, the major reason was lack of familiarity with the application and smartphone device for clinical photography as well as a previously established clinical photography practice using a digital camera.

Eligible patients were those who would have had their photograph taken regardless of whether or not the study was being conducted and were recruited by the participating surgeons described earlier. The application was explained to the patients, and their parents, if the patient was younger than 18, and they were asked to complete both the written consent to participate in the study and the electronic consent incorporated in the application prior to having their photograph taken. The patients, or parents, who participated in the study were later sent a survey electronically. The purpose of the 11-question survey was to gauge their thoughts on having their photograph taken using the application, perception of their information security using various means of clinical photography, including the ShareSmart application, and for which purposes they would provide consent for photography (eg, research, communication, and education).

Results

Patient Survey Responses

Over the 1-year trial period, 84 patients, and parents of patients, participated with a 56% (47/84) survey response rate. Because the surveys were anonymized, we were not able to tell the proportion of adult patients versus parents of children who responded. All photographs were captured during hospital clinic, inpatient, or emergency visits.

Consent

The large majority of respondents (98% [46/47)]) felt that the purpose of the application was well explained to them and did not feel pressure to consent (98% [46/47]). Patients overall felt that ShareSmart was an acceptable means of providing consent (89% [41/47]), with only 10% (5/47) responding that they would have preferred a pen and paper (1/5 preferred physically signing a piece of paper and 4/5 stated that they had provided written consent for the application, confusing the consent to participate in the study with the incorporated application consent). When asked the purposes to which they would consent to having their photograph taken, 91% (42/47) would consent for educational purposes to be utilized by medical professionals, 91% (43/47) for inclusion in their medical record, 85% (39/47) to enhance communication with their patient care team, 76% (35/47) for research purposes, and 4% (2/47) wouldn’t want their photograph taken in any circumstance.

Photograph security

Overall patient perception of their information security was quite high with all methods. The most safety was perceived with Sharesmart (89% [42/47]) and digital camera (83% [40/47]) and the least with the smartphone camera (63% [29/47]). Lack of safety was due to concerns regarding who could potentially access the data outside those required to do so (2/47 with ShareSmart, 8/47 with digital camera, and 14/47 with smart phone camera), lack of clarity on how the photograph would be used (1/47 for ShareSmart, 1/47 for digital camera, and 1/47 for smart phone camera), that their photograph would be on social media (1/47 with smart phone camera), and that they didn’t know anything about the method of photography (1/47 for ShareSmart).

General comments

When asked for comments regarding the application, patients expressed that “this is a great idea” as well as it being “an awesome technology that can help a lot of people.” Concerns were also expressed, with one respondent stating “I do not wish to have my son’s pictures shared in any medical textbook or in a lecture on a big screen somewhere,’ and others worried that ‘there’s no guarantee that it won’t be shared outside of medical purposes’ and ‘they can be uploaded anywhere’.”

Surgeon and Resident Survey Responses

Over the trial period, 16 Calgary plastic surgeons and 24 residents used the application, with a 51% (22/40) survey response rate.

Prior to the use of ShareSmart

  • a. Method of clinical photography and photograph transmission

Prior to the trial, the surgeons and residents primary method of clinical photography was their smartphone camera (77% [17/22]), followed by a digital camera (18% [4/22]), and one who denied taking photographs altogether (5% [1/22]). Of those who took clinical photographs (95% [21/22]), the large majority transmitted photographs for clinical purposes via direct transfer using text message (81% [17/21]), with the remaining 19% using various alternate methods (encrypted e-mail (10% [2/21]), nonencrypted e-mail (5% [1/22]), and by providing a hard copy of the photograph (5% [1/22])).

  • b. Consent

Consent for clinical photography was primarily attained verbally (81% [17/21]), with the remainder either not obtaining consent or assuming implied consent (14% [3/21]), and 1 (5%) respondent who used the Alberta Health Services (AHS) written consent.

  • c. Photograph storage and security

Most respondents (38% [8/21]) stored their clinical photographs on their smartphone alone, 14% (3/21) on their smartphone and laptop, 14% (3/21) on their desktop alone, 5% (1/21) on their smartphone and desktop, 5% (1/21) on their laptop and desktop, and 5% (1/21) did not respond. To protect these photographs, half the respondents (48% [10/21]) used 1 password (eg, phone password), 24% (5/21) used a password and encryption, 10% (2/21) a 2-level password (eg, computer password and a password to access photograph file), 5% (1/21) used encryption, and 14% (3/21) did not respond. Half (48% [10/21]) backed up their stored photographs and half (52% [11/21]) did not.

  • d. Concerns with current clinical photography methods

Open-ended questioning revealed that surgeons using a digital camera as their primary method of clinical photography (4/22) were concerned with the slowness in gaining access to their photographs (25% [1/4]), poor organization of their photographs (25% [1/4]), mixing of their personal and professional photographs (25% [1/4), potential breach of patient confidentiality (25% [1/4]), and an inadequate consent process (25% [1/4]). Of those using their smartphone as their primary method of clinical photography (17/22), concerns included security of photograph transmission (41% [7/17]), photograph storage security (35% [6/17]), potential breach of patient confidentiality (24% [4/17]), inadequate consent process (24% [4/17]), and mixture of personal and professional photographs (6% [1/17]). One participant stated they had no concerns, as they did not include patient identifiers on their photographs (6% [1/17]),

Trial of ShareSmart

One respondent did not use ShareSmart to take a clinical photograph but did use the application to receive clinical photographs and for communication (5% [1/22]). Others responded that they used the application to take photographs 1 to 5 times (14% [3/22]), 6 to 10 times (9% [2/22]), or over 10 times (73% [16/22]). Almost all respondents used the application to receive (95% [21/22]) and send (95% [21/22]) patient photographs.

  • a. Consent

Respondents found the application’s consent to be better (73% [16/22]) or the same (23% [5/22]) as their prior method, with only 5% (1/22) who found it inferior (they used AHS written consent as their prior method). Most perceived the application’s consent to be adequate for inter-professional communication (91% [20/22]), educational purposes (77% [17/22]), and for inclusion in the patient record (68% [15/22]), with less finding it adequate for research purposes (36% [8/22]), publication (18% [4/22]), and disclosure to the public (eg, Internet, nonmedical journal; 14% [3/22]).

  • b. Photograph storage and security

When queried on secure methods to share clinical photographs with health-care providers, all respondents felt Sharesmart was secure (100% [22/22]), followed by encrypted e-mail (73% [16/22]), and no respondents found text messaging or regular mail secure (0% [0/22]). The majority of surgeons perceived that the application overcame issues of unintentional sharing of photographs (82% [18/22]), poor photograph storage (95% [21/22]), potential breach of patient confidentiality (77% [17/22]), and inadequate consent (68% [15/22]) present with their current methods of clinical photography. Over half believed that no issues remained using the application (59% [13/22]), but some perceived potential breach of confidentiality (14% [3/22]), inadequate consent (14% [3/22]), and unintentional sharing of photographs (5% [1/22]) as issues that remained.

  • c. Difficulties encountered using ShareSmart

Most encountered difficulty with the application at least once (77% [17/22]). Difficulties included technical difficulties (50% [11/22]), slow speed (23% [5/22]), issues when wi-fi or cellular data was not available (9% [2/22]), lack of familiarity (9% [2/22]), and that the incorporated consent was too long for the patients to read (5% [1/22]).

  • d. Suitability for broad implementation

Almost all respondents (96% [21/22]) believed Sharesmart was suitable for broad implementation. Of those, 67% (14/21) would use it as is, and 33% (7/21) would use it with modifications. Only 5% (1/22) preferred to use their digital camera, and no one preferred the use of their smartphone camera (0% [0/22]). Suggestions for improving the application consisted of resolving technical difficulties (23% [5/22]), improving speed (23% [5/22]), adding the ability for video content (5% [1/22]), and adding a desktop modality (5% [1/22]).

Discussion

A review of the Canadian provincial and territorial medical regulatory college guidelines surrounding clinical photography found that these guidelines were either difficult to access or simply unavailable.33 A study done in the United Kingdom demonstrated similar findings.35 The recent development of Canadian national clinical photography guidelines33,34 with a focus on smart-device photography was an important step toward addressing the issues with the current state of clinical photography by providing a clear framework for providers to optimize patient security. The application ShareSmart yields a practical clinical photography medium that takes into consideration current technological times and all facets of these guidelines, offering a means for providers to efficiently take patient photographs while prioritizing patient security.

In 2010, only 2 years after the first iPhone launch, when patients were asked which device they found acceptable for clinical photography, the majority indicated hospital equipment as an acceptable method (75%), and significantly less were comfortable having their image captured using a smartphone or personal camera (12% and 16%, respectively).36 As smartphone usage has become increasingly ubiquitous, more recent studies demonstrate that patients understand the value of clinical photography and are accepting of it using personal devices.10,37,38 In our study, patients felt most happy consenting to photography for clinical communication (91%) and educational purposes (85%). The patient response to the use of ShareSmart to capture their photographs was favorable (81% preferred ShareSmart as one of their photography modalities or had no preference) and conveyed a sense of security (89%) comparable to a digital camera (83%). Perhaps media attention in the recent years to the holes in security with current clinical photography methods has increased public awareness, as our trial in 2015 of PicSafe Medi using a similar patient survey found an even higher perception of information security using the PicSafe Medi application (100%), digital camera (100%), and regular smart phone camera (89%).10

While patient’s perception of ShareSmart was similar to the previously trialed PicSafe Medi (77% preferred PicSafe Medi as one of the photography modalities or had no preference), surgeon response was far more favorable toward ShareSmart. In contrast to 23% of surgeons who would have used PicSafe Medi without modifications, 67% of survey respondents would use ShareSmart as is, and no respondents preferred their smartphone camera (in contrast to 15% in the prior study). Notably, in both studies, the preference for digital camera use was close to none (0% PicSafe Medi trial and 5% ShareSmart trial), highlighting the utility of a clinical photography application. The contrast in surgeon response between the 2 applications that provided similar features with on-application photography, consent, and photograph storage and transmission, demonstrates the importance of interface to facilitate broad adoption. ShareSmart was easy to use, provided high-quality photographs, and included a simple interapplication messaging system.

Education regarding appropriate consent and appropriate protection of images remains an important facet in the field of clinical photography and should include instruction on ethics, methods to optimize smartphone photography, and guidelines.8,39,40 Although the ShareSmart application provides a secure option for most facets of clinical photography, 18% of surgeon respondents did not think its consent was sufficient for photograph publication. In the United Kingdom, 3 levels of consent for clinical photography exist, with publication being the highest.35 Both the “Plastic Surgery”41 and “Plastic and Reconstructive Surgery”42 journals recommend that all non-necessary identifying material (name, birth date etc) on a photograph be removed for publication purposes. Additionally, “Plastic Surgery”41 requires that written consent be obtained and the patient be shown the manuscript prior to publication recognizing that even “de-identified photographs” can still have identifying features. “Plastic and Reconstructive Surgeries”42 have their own consent forms for photograph release and also recommend that any consent for photograph publication include permission to “use photographs for all types of media including but not limited to the following: print, visual, electronic, or broadcast media,” which is not currently included in the ShareSmart consent. Thus, when photographs are intended for publication purposes, a more in-depth conversation should occur, journal-specific requirements should be adhered to, and additional consent forms should be obtained.7,43

Limitations of this study included the small sample size as well as responder bias. It is possible that those who responded to the online survey represent a group that is more comfortable with technology and thus the ShareSmart application. This study sampled a group of surgeons and residents who work in busy teaching hospitals and may represent a different set of needs than those in the community or practicing in other specialties. Limitations remain with the ShareSmart application, namely, technical glitches, slower speed than the regular smart phone camera, and lack of video capability and a desktop platform. In discussion with the application developers, steps to overcome these limitations are being undertaken.

Overall, ShareSmart meets all of the national guideline recommendations, including consent, encrypted transmission of patient information and photographs, storage of clinical photographs on a secure encrypted Canadian cloud separate from the smartphones intrinsic storage system, and presence of an audit trail keeping track of the parties who have accessed and transmitted the photograph. It appears to be well accepted by the patients and surgeons who responded to the survey and is to our knowledge the best available platform that offers a solution to the issues faced with current clinical photography practices.

Conclusions

A smartphone clinical photography and communication application, ShareSmart, addresses the risks of patient confidentiality breach present with current photography methods. It meets national guidelines for clinical photography, is well accepted by surgeons who have trialed it for its user friendly interface, and should be considered for broad implementation.

Footnotes

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD: Danielle O. Dumestre, MD, FRCSC Inline graphic https://orcid.org/0000-0001-6725-0221

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